癌症疼痛的评估和管理

目的通过对癌症疼痛的评估和管理,给予癌痛患者规范化治疗和护理,减轻患者痛苦。方法对入院评估存在疼痛31例癌痛患者,建立疼痛病历疼痛情况调查表、疼痛评估单、不良反应记录单;把疼痛作为第五生命体征,纳入日常工作,将疼痛量化绘制成线图,为医生疼痛的管理提供可靠的依据,最大限度降低药物的不良反应。结果入院后4h平均分最高,以后逐渐降低,可能与患者刚入院后环境的不适应而加重了疼痛有关,通过疼痛的规范化管理后24、48h平均分呈稳定状态。结论疼痛的规范化管理需要医护人员的通力合作,现代医疗水平完全可以做到让患者无痛生活。     

Evaluation and management of breast pain

Pain is one of the most common breast symptoms experienced by women. It can be severe enough to interfere with usual daily activities, but the etiology and optimal treatment remain undefined. Breast pain is typically approached according to its classification as cyclic mastalgia, noncyclic mastalgia, and extramammary (nonbreast) pain. Cyclic mastalgia is breast pain that has a clear relationship to the menstrual cycle. Noncyclic mastalgia may be constant or intermittent but is not associated with the menstrual cycle and often occurs after menopause. Extramammary pain arises from the chest wall or other sources and is interpreted as having a cause within the breast. The risk of cancer in a woman presenting with breast pain as her only symptom is extremely low. After appropriate clinical evaluation, most patients with breast pain respond favorably to a combination of reassurance and nonpharmacological measures. The medications danazol, tamoxifen, and bromocriptine are effective; however, the potentially serious adverse effects of these medications limit their use to selected patients with severe, sustained breast pain. The status of other therapeutic strategies and directions for future research are discussed.     

髌股关节疼痛及其临床治疗的研究

概述过去十年作者在实验室进行有关髌股关节及髌股关节疼痛综合征(PFPS)的研究,研究了正常人髌股关节的几个指标及PFPS患者的康复成效。研究结果反映股内侧肌(VMO)对于控制髌股关节的压力分布所发挥的力学作用、下肢方位对促进VMO募集的影响,以及髌骨叩压、股四头肌的疲劳恢复与生物反馈辅助对PFPS康复治疗的作用。     

Improving pain management after total joint replacement surgery

PURPOSE: To test the effects of implementing evidence-based postoperative pain management content and strategies on patient, provider (nurse and physician), and fiscal outcomes. SAMPLE: 118 patients, 57 before and 61 after implementation, having total knee replacement (TKR) (54%) and total hip replacement (THR) (45%), and 28 orthopaedic nurses. METHODS: A research utilization approach with a pretest/posttest design was used. Independent variables (interventions) included evidence-based pain management content, education of care providers and patients, and system changes at the point of care. Dependent variables (outcomes) were patient perception of the postoperative pain experience, provider practice patterns, and length of stay (LOS). FINDINGS: The hypotheses of decreased provider use of meperidine and increased use of hydromorphone, i.v. route, pain plans of care, and nurse knowledge were supported. LOS was significantly reduced. The patient hypotheses decreased pain intensity and side effects and increased satisfaction and function were not supported. CONCLUSION: Methodical implementation of evidence-based pain management information changed practice and fiscal outcomes. Improvement in the patient perception of pain management was more difficult to achieve.     

Acute pelvic pain: Evaluation and management

Acute pelvic pain in women is often a diagnostic dilemma. Obstetrical, gynecological, urological or gastrointestinal causes must be considered. Stabilization, immediate therapy and early consultation are often indicated. If no etiology is found, conservative management with frequent re-evaluation is adequate. The authors have stated that they do not have a significant financial interest or other relationship with any product manufacturer or provider of services discussed in this article. The authors also do not discuss the use of off-label products, which includes unlabeled, unapproved, or investigative products or devices.     

Procedure-based nonsurgical management of lumbar zygapophyseal joint cyst-induced radicular pain

OBJECTIVE: To evaluate the success of fluoroscopically guided, contrast-enhanced lumbar zygapophyseal joint (Z-joint) aspiration and steroid injection combined with transforaminal epidural steroid injections (TFESIs) for the treatment of lumbar Z-joint cyst-induced radicular pain. DESIGN: Retrospective case series with independent follow-up. SETTING: Institutional, referral center. PARTICIPANTS: Twenty-three patients referred to a single provider for procedure-based management of radicular pain believed secondary to lumbar Z-joint cyst. Inclusion criteria consisted of lumbar radicular pain that was consistent with the level and side of the Z-joint cyst as a causative lesion. INTERVENTIONS: Eighteen patients were treated with a fluoroscopically guided, contrast-enhanced Z-joint aspiration and steroid injection at the level of the causative cyst coupled with a fluoroscopically guided, contrast-enhanced TFESI over the level of the presumably irritated spinal nerve. MAIN OUTCOME MEASURES: Patient satisfaction, and whether or not surgery was performed. RESULTS: Fifty percent of patients treated with the procedure had significant long-term benefit and avoided surgical intervention at an average follow-up of 9.9 months. CONCLUSIONS: Fluoroscopically guided, contrast-enhanced spinal procedures as part of an aggressive nonsurgical treatment program are a safe and effective alternative to surgical intervention for lumbar Z-joint cyst-induced radicular pain.     

Facet joint pain and the role of neural blockade in its management

Chronic spinal pain is a common medical problem with serious financial and social consequences. Among the various structures with potential for producing pain in the spine, facet joints as sources of chronic spinal pain have attracted considerable attention and controversy. Significant progress has been made in precision diagnosis of spinal pain with neural blockade, in the face of less than optimal diagnostic information offered by imaging and neurophysiologic studies. Research into the role of facet joints in spinal pain has shown that cervical facet joints are the cause of chronic neck pain in 54% to 60% of patients, whereas lumbar facet joints cause pain in 15% to 40% of patients with chronic low back pain. Local anesthetic blocks of medial branches have proven to be a reliable diagnostic test; they are target-specific when used appropriately with control blocks, either with two local anesthetics with different durations of action or with the addition of an inactive placebo injection. The literature is replete with reports on uncontrolled studies, case reports, and documentation from a few controlled studies, all of which offer supporting information on the rationale and effectiveness of facet blocks and neurotomy. Facet joint injections and medial branch blocks are considered to be of equal value. Lumbar intra-articular steroid injections have been proven effective to a certain extent, but evidence indicates that cervical intra-articular steroids are ineffective. The role of repeat medial branch blocks is not known. Radiofrequency neurotomy remains the only practical and validated treatment for cervical facet joint pain; however, its role in management of either lumbar or thoracic facet joint pain awaits validation.     

Evaluation and management of shoulder pain in primary care clinics

Shoulder pain is a frequent clinical problem facing primary care physicians. Despite its common occurrence, many clinicians are unfamiliar with the diagnosis and treatment of many common shoulder ailments. Because therapy for most shoulder disorders can be made at the initial consultation, a good history and physical remain paramount. The purpose of this paper is to review the basic approach to diagnosis and management of shoulder pain. It will summarize a pragmatic approach to the initial history, with particular attention to differentiating extrinsic and intrinsic etiologies. Physical exam techniques for evaluating shoulder pain will be reviewed, including provocation testing for specific disorders. Specific disorders covered include supraspinatus tendonitis, subdeltoid bursitis, frozen shoulder, biceps tendonitis, and acromioclavicular (AC) joint arthritis.     

Evaluation and management of the patient with acute back pain

Patients with low back pain are among the largest group of health care consumers today. During an episode of acute back pain the patient may be hospitalized for diagnostic workup and medical management, processes to which occupational therapists can contribute. The occupational therapist's evaluation includes assessment of the patient's activities of daily living and understanding of back protection and pain behaviors. The therapist involves the patient in managing his or her back problem by teaching problem-solving skills and identifying appropriate life-style changes. Instruction is provided in proper body mechanics, anatomy of the spine, work simplification, relaxation, and adaptive methods of performing daily activities. Given the short hospitalization period, outpatient follow-up may be provided to facilitate the application of information learned in the hospital to home and work settings. The goal of occupational therapy is to help the patient with low back pain return to a productive life-style.     

Evaluation of the physical management of low back pain

ERICA (European Research Into Consumer Affairs) is engaged in research into problems faced, notably by the underprivileged, in the countries of the European Economic Community (EEC). An early project investigated dial-a-ride systems for the transport of disabled people in six EEC countries. The object was to discover their successes and failures and pass on the information. In spite of national differences, many of the problems were the same. So, since the aim of all ERICA's research is action, the first step has been to publish guidelines for any voluntary organization or local authority aiming to set up a dial-a-ride.     

腰椎术后骶髂关节源性下腰痛的特点和治疗

目的探讨腰椎术后骶髂关节源性下腰痛的特点和治疗。方法 2006~2009年对64例腰椎术后骶髂关节源性下腰痛的患者进行回顾性研究。综合分析临床资料、体征及影像学表现,总结其临床特点,并予手法调整骶髂关节,辅予封闭术治疗,通过VAS、活动能力及改良Macnab标准来评定治疗疗效。结果随访8~42个月(平均22.7个月),患者治疗后的VAS评分(2.01±1.03)较治疗前(9.01±2.30)改善明显(P<0.01);活动能力评分(1.01±0.3)较治疗前(2.6±0.30)改善明显(P<0.01)。结论腰椎融合术后骶髂关节病变是引起术后下腰痛的重要原因之一,腰椎术后应力的改变导致的骶髂关节错位是骶髂关节源性下腰痛的主要原因。封闭是诊断骶髂关节源性下腰痛的最有效的方法,手法调整骶髂关节,辅予封闭术治疗该疾病的简单、安全、有效的方法。     

Temporomandibular joint pain and dysfunction

Pain caused by temporomandibular disorders originates from either muscular or articular conditions, or both. Distinguishing the precise source of the pain is a signi ficant diagnostic challenge to clinicians, and effective management hinges on establishing a correct diagnosis. This paper examines terminology and regional anatomy as it pertains to functional and dysfunctional states of the temporomandibular joint and muscles of mastication. A review of the pathophysiology of the most common disorders is provided. Trends in evaluation, diagnosis, treatment, and research are presented.     

Cervical zygapophysial (facet) joint pain: effectiveness of interventional management strategies

Diagnostic facet joint nerve blocks have been utilized in the diagnosis of cervical facet joint pain in patients without disk herniation or radicular pain due to a lack of reliable noninvasive diagnostic measures. Therapeutic interventions include intra-articular injections, facet joint nerve blocks and radiofrequency neurotomy. The diagnostic accuracy and effectiveness of facet joint interventions have been assessed in multiple diagnostic accuracy studies, randomized controlled trials (RCTs), and systematic reviews in managing chronic neck pain.

This assessment shows there is Level II evidence based on a total of 11 controlled diagnostic accuracy studies for diagnosing cervical facet joint pain in patients without disk herniation or radicular pain utilizing controlled diagnostic blocks. Due to significant variability and internal inconsistency regarding prevalence in a heterogenous population; despite 11 studies, evidence is determined as Level II. Prevalence ranged from 36% to 67% with at least 80% pain relief as the criterion standard with a false-positive rate ranging from 27% to 63%.

The evidence is Level II for the long-term effectiveness of radiofrequency neurotomy and facet joint nerve blocks in managing cervical facet joint pain. There is Level III evidence for cervical intra-articular injections.     

Modern management of mild-to-moderate joint pain due to osteoarthritis: a holistic approach

Osteoarthritis (OA) is the most common form of arthritis and it is often associated with significant disability and impaired quality of life. Once thought to be caused by an age-related 'wearing out' of articular cartilage, it is now recognized to be a dynamic process in which cartilage degradation alternates with repair. Several expert guidelines for the management of OA exist, which concur in their recommendations for a stepwise approach to the employment of pharmacological agents and the introduction of suggestions to extend the use of agents such as topical non-steroidal anti-inflammatory drugs, especially for mild-to-moderate forms of the disease. They also emphasize the importance of non-pharmacological measures, such as nutraceuticals, education, diet, exercise and the use of aids in improving signs and symptoms and slowing progression. In many countries, effective medicinal and nutraceutical agents are available 'over-the-counter'. This review explains the modern approach to the management of mild-to-moderate osteoarthritic pain.     

癌症病人疼痛管理教育效果评价

[目的]确定疼痛管理教育对减轻癌症病人疼痛的有效性.[方法]采用癌症病人疼痛调查表对90例肿瘤晚期疼痛病人进行调查,将病人分为实验组和对照组,每组45例,对照组进行常规护理,实验组根据回答情况对45例病人所存在的错误认识进行教育,干预后第3周再次对两组病人进行调查.[结果]通过疼痛管理教育,实验组病人对疼痛知识了解显著提高,疼痛程度较干预前明显下降(P<0.01).[结论]疼痛管理教育可以帮助病人获得管理疼痛的知识和技能,从而减轻疼痛,提高病人生活质量.